Nursing Elites

1. A client receiving preoperative instructions asks questions repeatedly about when to stop eating the night before the procedure. The nurse tries to refocus the client. The nurse notes that the client is frequently startled by noises in the hall. Assessment reveals rapid speech, trembling hands, tachypnea, tachycardia, and elevated blood pressure. The client admits to feeling nervous and having trouble sleeping. Based on the assessment, the nurse documents that the client has:

• A. mild anxiety.
• B. moderate anxiety.
• C. severe anxiety.
• D. a panic attack.

Correct answer: C

Rationale: The correct answer is 'severe anxiety.' In severe anxiety, a person focuses on small or scattered details and is unable to solve problems. The client's symptoms of rapid speech, trembling hands, tachypnea, tachycardia, elevated blood pressure, feeling nervous, and having trouble sleeping indicate severe anxiety. Mild anxiety enhances the ability to learn and solve problems, while moderate anxiety narrows the perceptual field but allows the client to notice things brought to their attention. During a panic attack, a person is disorganized, hyperactive, or unable to speak or act, which is not the case in this scenario.

2. Which statement reflects a primary belief of psychiatric mental health nursing?

• A. Most people have the potential to change and grow.
• B. Every person is worthy of dignity and respect.
• C. Human needs are individual to each person.
• D. Some behaviors have no meaning and cannot be understood.

Correct answer: B

Rationale: The correct answer reflects a primary belief of psychiatric mental health nursing, which is that every person is worthy of dignity and respect. This belief forms the foundation of providing holistic and compassionate care in mental health nursing. While it is true that most people have the potential to change and grow, this choice does not directly address a core belief of mental health nursing. Human needs being individual to each person is a general principle of nursing care but does not specifically capture a primary belief in psychiatric mental health nursing. The statement that some behaviors have no meaning and cannot be understood contradicts the fundamental principle that all behavior has meaning and can be understood from the client's perspective in psychiatric mental health nursing.

3. What is the profile of an individual who engages in domestic violence?

• A. from a minority culture in a low-income group.
• B. from a majority culture in a middle-income group.
• C. one who was never allowed to compete as a child.
• D. from any walk of life, race, income group, or profession.

Correct answer: D

Rationale: Individuals who engage in domestic violence come from various backgrounds and cannot be stereotyped based on demographic factors like culture, income, or race. Research shows that perpetrators of domestic abuse can be found in any walk of life, regardless of their race, income group, or profession. It is important to note that the majority of domestic violence cases involve male perpetrators and female victims, but the profile of the abuser is not limited to specific demographic features. Therefore, the correct answer is that individuals who engage in domestic violence can come from any walk of life, race, income group, or profession. Choices A and B are incorrect as they wrongly associate domestic violence with specific cultural or income groups. Choice C is incorrect as there is no evidence to support the claim that being disallowed to compete as a child leads to domestic violence.

4. A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period?

• A. Teaching perineal wound care techniques
• B. Monitoring electrolyte levels
• C. Encouraging early ambulation
• D. Facilitating perineal wound drainage

Correct answer: D

Rationale: The priority nursing care during the post-op period for a client who underwent an abdominal perineal resection is to facilitate perineal wound drainage. This is crucial for preventing infection of the surgical site and promoting healing. Teaching perineal wound care techniques, as in choice A, is more appropriate than ileostomy care in this scenario. While monitoring electrolyte levels is important, it is not the priority compared to ensuring proper wound drainage, making choice B less crucial. Encouraging early ambulation, as in choice C, is beneficial but not as critical as facilitating wound drainage immediately post-op.

5. When assessing a client with glaucoma, a nurse expects which of the following findings?

• A. Complaints of double vision
• B. Complaints of halos around lights
• C. Intraocular pressure of 15 mm Hg
• D. Soft globe on palpation

Correct answer: B

Rationale: When assessing a client with glaucoma, a common finding is complaints of halos around lights. Other symptoms of glaucoma include loss of peripheral vision or blind spots, reddened sclera, firm globe, decreased accommodation, and occasional eye pain. Glaucoma may be asymptomatic until permanent damage to the optic nerve and retina occurs. Double vision is not a typical symptom of glaucoma. In terms of intraocular pressure, normal levels range from 10 to 21 mm Hg, making an intraocular pressure of 15 mm Hg within the normal range. A soft globe on palpation is not a typical finding in glaucoma.

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